Art of Medicine
Aug 2018

Cruel Carousel: The Grim Grind of “Compassionate” Dialysis

Nathan A. Gray, MD
AMA J Ethics. 2018;20(8):E778-779. doi: 10.1001/amajethics.2018.778.


In this graphic narrative, a clinician illustrates an experience of caring for an undocumented patient suffering from end-stage renal disease (ESRD). Cruel Carousel tells one of the stories that most profoundly shaped the author’s own views on health care for undocumented immigrants. Graphic narrative was chosen to tell this story because words alone couldn’t capture the patient’s experience or the author’s distress about what happened to him.

Figure. Cruel Carousel: The Grim Grind of “Compassionate” Dialysis

Figure 1 Cruel Carousel page image


The illustrations in this piece were created using Paper version 4.1.2 and Procreate version 4.0.10 for iPad.


More than 6 000 undocumented immigrants living in the United States suffer from ESRD; those who live in locations where funding is not provided for scheduled dialysis face a recurring cycle of critical illness experiences as they wait for emergency sessions of dialysis through hospitals and emergency departments. This approach to dialysis treatment results in tragic patient outcomes and distress for clinicians, who are left to provide undocumented patients with care that is dramatically different from standard dialysis delivery. Patients oscillate between being marginally well and “ill enough” to receive dialysis, while clinicians wrestle with complicity in a system that both offers and withholds life-saving therapy.


  1. Rodriguez RA. Dialysis for undocumented immigrants in the United States. Adv Chronic Kidney Dis. 2015;22(1):60-65.
  2. Cervantes L, Fischer S, Berlinger N, et al. The illness experience of undocumented immigrants with end-stage renal disease. JAMA Intern Med. 2017;177(4):529-535.
  3. Raghavan R, Nuila R. Suriviors – dialysis, immigration, and US law. N Engl J Med. 2011;364(23):2183-2185.
  4. Raghavan R. New Opportunities for funding dialysis-dependent undocumented individuals. Clin J Am Soc Nephrol. 2017;12(2):370-375.
  5. Sheikh-Hamad D, Paiuk E, Wright AJ, Kleinmann C, Khosla U, Shandera WX. Care for immigrants with end-stage renal disease in Houston: a comparison of two practices. Tex Med. 2017;103(3):54-58.


AMA J Ethics. 2018;20(8):E778-779.



Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose. 

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.